Highlights from AHCPR's August Research Activities

Media Advisory Date: September 17, 1997

The Agency for Health Care Policy and Research (AHCPR) works to improve the quality of health care, reduce costs, and broaden access to essential services. Here are some of the findings described in the most recent issue of AHCPR's Research Activities.

Prophylactic Mastectomy Provides Substantial Gains in Life Expectancy for Women With Cancer-Disposing Genes

Prophylactic mastectomy (surgical removal of the breasts) in women with mutations in BRCA1 and BRCA2 genes may substantially improve life expectancy, according to a study funded by AHCPR. Mutations in these genes markedly increase women's risk of breast and ovarian cancer. However, the study found that prophylactic oophorectomy (surgical removal of both ovaries) provides more limited gains in life expectancy. Researchers used decision analysis to compare these surgeries with no prophylactic surgery among women who carry BRCA1 and BRCA2 mutations while estimating the range of risks associated with these mutations. They found that, on average, 30-year-old women gain from 2.9 to 5.3 years of life expectancy from prophylactic mastectomy and from 0.3. to 1.7 years of life expectancy from prophylactic oophorectomy, depending on their cumulative risk of cancer. Researchers caution that neither procedure completely protects against cancer.

["Decision analysis—Effects of prophylactic and mastectomy and oophorectomy on life expectancy among women with BRCA1 and BRCA2 mutations," by Deborah Schrag, M.D., Karen M. Kuntz, Sc.D., Judy E. Garber, M.D., M.P.H., and Janice Weeks, M.D., in the May 15, 1997 New England Journal of Medicine 336, pp. 1465-1471.

Amoxicillin is Often Prescribed to Prevent Middle Ear Infections in Young Children, But it is Only Marginally Effective

Amoxicillin and other antibiotics are frequently used to prevent recurrent middle ear infections that affect 15 percent of children. But an AHCPR-supported study indicates that use of these antibiotics may not be a good idea. The study indicates that children with recurrent middle ear infections, that is 3 infections within 6 months or 4 in a year, fare about the same as children given a placebo, with 61 percent to 64 percent remaining free of new infections during the study period. Also, researchers say that the excessive antibiotic use, which has the potential to promote acquisition of antibiotic-resistant bacterial pneumonia, already is becoming more prevalent. Stephen Berman, M.D., of the University of Colorado Health Sciences Center, and colleagues suggest treating individual episodes. When a child has suffered from 5 or 6 recurrent episodes during one year, referral for surgical placement of a tube to drain persistent middle ear fluids should be considered.

["Roark, R. and Berman S., "Continuous twice daily or once daily amoxicillin prophylaxis compared with placebo for children with recurrent acute otitis media," Pediatric Infectious Disease Journal 16, pp. 376-381.]

Many Physicians Have Not Fully Adopted Recommended Cholesterol Management Practices

An AHCPR-supported study indicates that physicians have not fully adopted the cholesterol management practices first recommended in 1988 by the National Cholesterol Education Program. The study found that physicians screen only 1 in 12 patients annually for high cholesterol and counsel patients with hyperlipidemia (high levels of fat in the blood) about cholesterol reduction about once every 3 years. They are less apt to prescribe lipid-lowering medications for obese than nonobese persons and often these are not the recommended medications. Finally, some physicians do not account for multiple risk factors for heart disease, such as cigarette smoking, in their cholesterol management practices. More aggressive screening, counseling, and medication treatment for hyperlipidemia would help prevent heart disease, explains David Blumenthal, M.D., M.P.P., of Harvard Medical School. His team examined reports by 2,332 office-based physicians' on the use of cholesterol-related screening, counseling, or medications during 56,215 office visits during 1991 and 1992.

["Variations in cholesterol management practice of U.S. physicians," by Dr. Randall Stafford, M.D., Ph.D., David Blumenthal, M.D., and Richard C. Pasternak, M.D., in the January 1997 Journal of the American College of Cardiology 29, pp. 139-146.]

Duration of Maternity Work Leave Significantly Affects Maternal Health

Mothers with infants are one of the fastest growing segments of the labor force. However, a study partly supported by AHCPR indicates that the typical 6 weeks of maternity leave after childbirth may not be sufficient. Initially, less time off is associated with better health, but this relationship reverses itself at later stages of postpartum when more time off is associated with better health. Researchers used a theoretical model of health and workforce participation and a sample of women from state vital statistics records to analyze the relationship between maternal postpartum health and time off work after childbirth. They found that women who took more than 12 weeks leave experienced improved vitality, women with more than 15 weeks leave reported didn't feel depressed or nervous, and women who took more than 20 weeks leave felt better able to function socially. Of the study subjects, 75 percent of the women studied had returned to work by 12 weeks, 85 percent by 15 weeks, and 91 percent by 20 weeks after childbirth. By 7 months after childbirth, a substantial proportion of women experienced diminished levels of well-being. This supports the delayed effect of shorter maternity leaves demonstrated in other studies, notes Patricia McGovern, Ph.D., the principal investigator.

["Time off work and postpartum health of employed women," Dr. McGovern, Bryan Dowd, Ph.D., Dwenda Gjerdingen, M.D., and others, in Medical Care 35 (5), pp. 507-521.]

Other articles in Research Activities include findings on:

• Removal of both ovaries and a woman's risk of for heart disease.
• The cost of home care for ventilator-assisted persons.
• Race differences in the health of elders who live alone.
• Factors affecting home help for disabled elderly persons.
• Causes of death in homeless adults.
• Differences in diagnosis of tuberculosis among men and women.
• Impact of sexually transmitted diseases on birth outcomes.
• Multimedia programs that can aid decisions about prostate surgery.
• HMOs: Are they losing their competitive advantage?
• Influence of body weight on surgical complications.
• U.S.-Canada differences in use of cardiac procedures.
• Why current triage guidelines may be impractical and harmful.
• Program to prevent or postpone risk behaviors among youth.
• Program to reduce spinal surgery among injured workers.
• Limitations of goals of care in advance directives.
• Future directions of primary care research.
• How consumers choose health plans.

For additional information, contact AHCPR Public Affairs: Karen J. Migdail, (301) 427-1855 (KMigdail@ahrq.gov) or Salina Prasad (301) 427-1864 (SPrasad@ahrq.gov).